Healthcare Provider Details

I. General information

NPI: 1003118316
Provider Name (Legal Business Name): AVALON MEDICAL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/19/2010
Last Update Date: 12/01/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

608 HWY 178
SHERMAN MS
38869
US

IV. Provider business mailing address

1413 W QUITMAN ST
IUKA MS
38852-1130
US

V. Phone/Fax

Practice location:
  • Phone: 662-840-1230
  • Fax:
Mailing address:
  • Phone: 662-424-9550
  • Fax: 662-424-9558

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: ANTHONY PRATHER
Title or Position: BUSINESS MANAGER
Credential:
Phone: 662-424-9550